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Medicare cracks down on power wheelchair claim fraud, but the bigger danger may be to health

Jo Nost had to see her family doctor, her rheumatologist, a physical therapist and a power wheelchair supplier to qualify for her scooter.

SKIP O’ROURKE | Times

Jo Nost had to see her family doctor, her rheumatologist, a physical therapist and a power wheelchair supplier to qualify for her scooter.

TAMPA — Michelle Provenzano hears the question every so often from patients getting ready to leave Florida Hospital Tampa's acute rehabilitation unit.

"Can I get one of those power wheelchairs?"

The answer is almost always no. "Most patients we see don't qualify" to have it paid for by Medicare or other insurance, said Provenzano, a social worker in the rehab unit.

"And they're disappointed."

Whether covered by insurance or not, many Americans have power wheelchairs and scooters, as anyone visiting a supermarket or shopping mall can attest.

Now Medicare says it has been spending far too much on them, and Florida is one of the first states where the agency is cracking down.

In 2009, the most recent year for which figures were available, Medicare spent $723 million on power wheelchairs and scooters. And after a study, the agency estimated that at least 60 percent of claims were paid despite shoddy paperwork or were for devices that the recipient didn't need.

Florida, with one of the highest rates of fraudulent claims in the nation, is among seven states that as soon as June 1 will not let anyone take a Medicare-funded power wheelchair home until the purchase is scrutinized and approved. Traditional Medicare has not tried such a prior authorization program before, and this three-year pilot could be expanded to other types of expenditures, too.

But the crackdown, aimed at making sure power chair recipients meet Medicare's criteria for medical necessity, does nothing about what some health professionals believe is a bigger threat: For people with the potential to walk again, what has been marketed as "mobility devices'' have the opposite impact. Rather than being their ticket to independent living, the chairs take away their incentive to walk, speeding their decline.

"They're motorized couches," said Dawn Etman, a nurse and program manager of the Florida Hospital Tampa rehab unit. "People can get so dependent on them."

• • •

The seven states — Florida, California, Illinois, Michigan, New York, North Carolina and Texas — account for 43 percent of what Medicare spends each year on power wheelchairs and scooters. All told, this category has grown from $259 million in 1999 to $723 million in 2009.

The seven states also have among the highest rates of Medicare fraud and improper payments, which is why they were selected for the project, said Melanie Combs-Dyer, a deputy director at the Centers for Medicare and Medicaid Services whose job it is to make sure device providers follow the rules.

How much is Medicare losing? A review of power wheelchair claims for the first part of 2007 found that more than half of $189 million in claims were medically unnecessary or so poorly documented it was impossible to tell whether they were needed, resulting in $95 million in improper payments.

In some cases, chairs have been sold using the name of an unwitting Medicare recipient who didn't need it and never got it — but then couldn't get one when they did need it.

Patients can't get the chairs without a doctor's prescription, and paperwork is submitted by businesses that sell devices, so the agency says it's the providers it is watching, not patients.

But many people who are disappointed when they don't get approval don't understand what Medicare considers "medically necessary." That's based solely on whether you can't get around in your home and perform routine tasks, not whether you need it to grocery shop.

Advertising has confused people, Combs-Dyer said.

"Some Medicare patients don't realize that, especially when they see a commercial with the elderly woman going to Disney," Combs-Dyer said. "And physicians (who prescribe the devices) can sometimes forget that."

Those eligibility requirements will not change June 1 — but you'll have to prove you qualify before you take delivery of a device that can cost more than $10,000.

Medicare's biggest concern is outright fraud, not innocent paperwork errors, officials say. Just last month, a Los Angeles pastor was sentenced to three years in federal prison for a scheme that used phony documents to bill Medicare for more than $14 million in power wheelchairs and other pricey equipment that never made it to the patients named on the documents or was unnecessary. Also last month, a Texas man was convicted for a similar power wheelchair scheme that involved submitting false statements to Medicare and using doctors' identities without permission to make fraudulent claims.

"These are very expensive items," Combs-Dyer said. "We need to preserve the Medicare trust fund the best way we can."

• • •

Getting a power wheelchair or scooter from Medicare shouldn't be as easy as it seems on TV.

The rules call for a face-to-face examination by a doctor, a seven-part written prescription, a detailed product description from the supplier signed by the doctor, and a home assessment by the supplier.

Mark Miklos is president of Primetime Medical, a durable medical equipment business in Largo that does 60 percent of its business in power wheelchair sales. If providers are doing what they're supposed to do, "they have nothing to worry about," he said of the coming crackdown.

To get her chair, Jo Nost, 75, had to see her family practice doctor, her rheumatologist, a physical therapist and a power wheelchair supplier.

"They observed me doing different things, bending, testing my range of motion," said the New Port Richey woman, who has cervical and spinal stenosis. "It was pretty thorough."

Nost spent more than 20 years using a cane and a walker to help her get around. Torn rotator cuffs made a manual wheelchair out of the question.

Last October, she got her power wheelchair.

"I'm very elated," she said. "I tell people if there's a need, see the right doctor."

• • •

Dr. William Quillen, who directs the University of South Florida's school of physical therapy and rehabilitation science, agrees that some people really do need these devices.

"But there are also people you see at Target, Walmart or the mall (using power devices), and there doesn't appear to be any readily apparent medical need," he said.

But if you're capable of rehabilitation, the longer you spend in a power chair makes it more likely you'll never get out of it.

"They lose muscle strength and gain weight," said Kavita Jain, a therapy team leader at the Florida Hospital rehab unit. "We view it as equipment of last resort."

Etman said she thinks some doctors don't want to lose a patient by taking a tough stand, and so they sign the prescription.

"But they don't realize that it's hindering the patient, not helping them," she said.

Quillen said patients often ask about power chairs and scooters.

"Our first line of response is, 'let's not get down that road until we complete your rehab,' " he said. "We're not going to throw in the towel."

Staying active is especially important for people with chronic conditions such as diabetes, heart disease and obesity.

"It's kind of move it or lose it," said Dr. Richard Morrison, a Tampa heart surgeon. "We want them up and moving. If they stop that . . . (their) cardiovascular system isn't going to be in good shape."

Etman said she sometimes gets patients who have used a power chair for years.

"They hate us," she laughed. "We're trying to get them to where they can use a walker or a cane, or nothing, and they don't want to."

Times researcher Natalie Watson contributed to this report. Richard Martin can be reached at rmartin@tampabay.com or (813) 226-3322.

How to spot fraud and abuse

Starting Saturday, Medicare's secure website (mymedicare.gov) goes to a more consumer friendly format that will make it easier for recipients to see if their information is being used for fraudulent purposes. Let Medicare know and you could get a $1,000 reward. Here are other clues to look for:

• Sales people offer you a ''free'' wheelchair or scooter, or offer to waive your co-payment.

• Someone bills Medicare for equipment you never received.

• Someone bills Medicare for a power wheelchair after it has been returned.

If you suspect billing fraud, contact Medicare toll-free at 1-800-633-4227.

Medicare cracks down on power wheelchair claim fraud, but the bigger danger may be to health 03/08/12 [Last modified: Thursday, March 8, 2012 11:07pm]
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